Adolescent subdural empyema in setting of COVID-19 infection: illustrative case

Abstract

BACKGROUND Coronavirus disease 2019 (COVID-19) is an ongoing viral pandemic that has affected modern medical practice and can complicate known pathology. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes symptoms that may mimic a viral pneumonia, with potential for serious sequelae, including acute respiratory distress syndrome, coagulopathy, multiorgan dysfunction, systemic vascular abnormalities, and secondary infection. OBSERVATIONS The authors describe a case of a 15-year-old boy who presented with a right subdural empyema and sinusitis while having active COVID-19 infection. The patient initially presented with left-sided weakness, frontal sinusitis, and subdural empyema. Emergent surgery was performed for evacuation of empyema and sinus debridement. Samples of purulent material within the subdural space were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. The patient had a successful recovery and regained the use of his right side after combined treatment. To our knowledge, this is the first reported case of a bacterial subdural empyema associated with frontal sinusitis in a coinfected patient with COVID-19 without evidence of COVID-19 intracranial infection. LESSONS A subdural empyema, which is a surgical emergency, was likely a superinfection caused by COVID-19. This, along with the coagulopathy caused by the virus, introduced unique challenges to the treatment of a known pathology.

Intracranial Empyemas in the COVID-19 Era: A New Phenomenon? A Paediatric Case Series and Review of the Literature

“…Separately, a more typical meningitis has also been described across several case reports [11,12]. Subdural empyemas have been reported following COVID-19 infection in a small number of adults [13,14], with three paediatric cases also described [14][15][16]. In this article, we report a marked increase in the incidence of IE since the beginning of the pandemic in our region, as well as a series of paediatric patients with subdural empyema directly following COVID-19 infection.…”

“…Across 3 patients, the COVID-19 diagnosis preceded identification of empyema diagnosis by 20-54 days [13,14,17]; in 2 patients, the diagnoses of empyema and COVID-19 were concurrent [15,16]. Empyemas reported in the literature were convexity (n = 3), parafalcine (n = 1), and intraventricular (n = 1) [13][14][15][16][17] (Table 3).…”

“…A literature review identified 608 relevant articles using the above search terms. Of these, 5 papers described purulent intracranial infections directly associated with COVID-19 infections: 2 adult case reports and 3 paediatric [13][14][15][16][17]. Clinical data for these reports are summarised in Table 3.…”

“…One patient initially developed hydrocephalus secondary to meningitis while in ICU being treated for COVID-19 pneumonia; only on internalisation of a ventriculoperitoneal shunt and subsequent deterioration was the empyema diagnosed [14]. Across 3 patients, the COVID-19 diagnosis preceded identification of empyema diagnosis by 20-54 days [13,14,17]; in 2 patients, the diagnoses of empyema and COVID-19 were concurrent [15,16]. Empyemas reported in the literature were convexity (n = 3), parafalcine (n = 1), and intraventricular (n = 1) [13][14][15][16][17] (Table 3).…”

Spontaneous subdural effusion in a hospitalized Covid-19 patient: Case report

“…In total, 5 cases were found in our literature review, and all of them had one thing in common: the presence of bacterial rhinosinusitis concomitant with Covid-19, confirmed by imaging and/or culture tests 8 , 9 , 10 . In all 5 cases, subdural empyema turned out to be a complication of bacterial superinfection, confirmed by subdural fluid culture, which showed bacterial growth and negative PCR for Covid-19.…”